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Role of Preoperative Esophagogastroduodenoscopy (EGD) in Bariatric Treatment

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Role of Preoperative Esophagogastroduodenoscopy (EGD) in Bariatric Treatment Journal of Clinical Medicine Article Role of Preoperative Esophagogastroduodenoscopy (EGD) in Bariatric Treatment Regina Sierzantowicz˙ 1,*, Jerzy R. Ładny 2 , Krzysztof Kurek 3 and Jolanta Lewko 4 1 Department of Surgical Nursing, Medical University of Bialystok, 15-274 Bialystok, Poland 2 Department of General and Endocrine Surgery, Medical University of Bialystok, 15-276 Bialystok, Poland; [email protected] 3 Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, 15-276 Bialystok, Poland; [email protected] 4 Department of Primary Health Care, Medical University of Bialystok, 15-054 Bialystok, Poland; [email protected] * Correspondence: [email protected] Abstract: Background: The recommendations for routine preoperative esophagogastroduodenoscopy (EGD) in patients qualified for bariatric surgeries are still a matter of debate. The aim of this study was to analyze the pathologies on preoperative EGD in patients qualified for bariatric surgeries. Materials and Methods: This study included 222 patients, divided into two groups. The obesity group consisted of patients with obesity (BMI ≥ 40 kg/m2), for whom EGD was a routine part of the preparation for laparoscopic sleeve gastrectomy (LSG). The control group of patients with normal body weight (BMI) qualified for EGD because of gastrointestinal ailments. Results: Regarding pre- operative EGD in patients qualified for bariatric surgeries, we analyzed the prevalence of endoscopic pathologies in various gastrointestinal tract segments. Patients with obesity were shown to present with esophageal pathologies significantly more often than persons in the control group (n = 23, 20.91% n p Citation: Sierzantowicz,˙ R.; Ładny, vs. = 12, 10.91%, = 0.042). The odds ratio of esophageal pathologies in patients with obesity versus J.R.; Kurek, K.; Lewko, J. Role of the control group equaled 2.15 (95%CI: 1.01–4.59). In turn, the odds ratio of duodenal pathologies Preoperative in patients from the control group was 3.31 (95%Cl: 1.16–9.47), which means that persons from this Esophagogastroduodenoscopy (EGD) group were approximately three times more likely to be diagnosed with those pathologies compared in Bariatric Treatment. J. Clin. Med. to obese patients. Moreover, patient sex was a significant predictor of duodenal pathologies, with an 2021, 10, 2982. https://doi.org/ odds ratio of 4.03 (95%CI: 1.53–10.61). Conclusions: Preoperative EGD can identify a broad spectrum 10.3390/jcm10132982 of pathologies in obese patients, which suggests a routine examination before bariatric surgery. Academic Editor: H. Christian Weber Keywords: preoperative esophagogastroduodenoscopy (EGD); morbid obesity; bariatric surgery Received: 26 May 2021 Accepted: 2 July 2021 Published: 3 July 2021 1. Introduction ≥ 2 Publisher’s Note: MDPI stays neutral Obesity, defined as a body mass index (BMI) 30 kg/m , is a health problem that, with regard to jurisdictional claims in according to 2014 estimates, affects more than 600 million adults worldwide [1]. The main published maps and institutional affil- cause of obesity is the accumulation of adipose tissue in an amount that considerably iations. exceeds the physiological and adaptive needs of the body. In obesity, both the number and the size of adipocytes increase due to persistent positive energy balance, and the synthesis of adipokines promotes the development of related metabolic disorders [2,3]. Treatment of patients with morbid obesity can be challenging and requires an individ- ualized approach. The primary goal of the treatment is to reduce the patient’s body weight Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. by 10% within three to six months. The most commonly used treatment modalities include This article is an open access article lifestyle modification, increase in physical activity, diet, and pharmacotherapy. Bariatric distributed under the terms and surgery is the most effective method to obtain a sustained reduction in body weight [4]. conditions of the Creative Commons The most frequently performed bariatric procedures are laparoscopic sleeve gastrectomy Attribution (CC BY) license (https:// (LSG) and Roux-en-Y gastric bypass (RYGB) [5]. creativecommons.org/licenses/by/ The indications for routine preoperative esophagogastroduodenoscopy (EGD) in pa- 4.0/). tients qualified for bariatric surgeries are still a matter of debate. None of the American J. Clin. Med. 2021, 10, 2982. https://doi.org/10.3390/jcm10132982 https://www.mdpi.com/journal/jcm J. Clin. Med. 2021, 10, 2982 2 of 13 scientific bodies, such as the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic and Bariatric Surgery have specified uni- versal guidelines regarding preoperative EGD; instead, EGD is recommended in selected cases, i.e., in patients with suspected upper gastrointestinal pathologies [6]. According to the European Association for Endoscopic Surgery (EAES), all patients subjected to bariatric surgeries should be examined for potential pathologies of esophageal, gastric, and duodenal mucosa, as well as for hiatal hernia and colonization with Helicobacter pylori [7]. Some studies have demonstrated that routine EGD before a bariatric procedure could identify some pathologies, such as hiatal hernia, esophagitis, ulcers, and tumors [8]. More- over, research has shown that the outcomes of bariatric surgeries in patients colonized with Helicobacter pylori are less favorable, as the presence of this microorganism contributes to a longer hospital stay and poses a risk of carcinomatosis within the intact portion of the stomach. Moreover, colonization with Helicobacter pylori may be associated with a more frequent occurrence of postoperative symptoms from the large intestine, most of- ten abdominal pain, nausea, and vomiting [9]. However, the results of some studies are inconclusive on this matter, suggesting that colonization with Helicobacter pylori is not related to the incidence of early postoperative complications and, hence, preoperative EGD may not be necessary [10]. Furthermore, the results of some studies seem to support selective EGD, solely in patients presenting with gastroesophageal ailments [11]. However, gastrointestinal surgeons have not reached a consensus regarding the cost-effectiveness of EGD; these controversies constitute the rationale for our present study. It is essential to diagnose and correct comorbidities to obtain good results in bariatric surgery. Non-invasive tests are used for the subjective assessment of a patient’s health and quality of life. Most often, these are questionnaires, the combined use of which is aimed at improving the detection of various disorders, e.g., voice disorders [12]. The aim of this study was to analyze pathologies found in preoperative EGD in patients qualified for bariatric surgeries. Moreover, this study verified whether patients with morbid obesity and normal body weight differ in terms of the frequency of clinical manifestations and pathologies found during preoperative EGD. 2. Materials and Methods 2.1. Study Population This study included 222 patients qualified for EGD admitted consecutively to the Diagnostic and Interventional Endoscopy Unit, University Clinical Hospital in Bialystok in 2018–2019. This unit is the largest center for endoscopy and bariatric surgery in Podlaskie Province, conducting the highest number of endoscopic, bariatric, and metabolic surgeries in northeastern Poland. Before EGD, a history of gastroesophageal ailments was collected from each patient and the medical documentation was analyzed. Those patients receiving H2 receptor antagonists, proton pump inhibitors (IPP), or acetylsalicylic acid were instructed to withdraw these medications 14 days before the examination. The medical histories and endoscopic findings were recorded and analyzed separately for the two groups: Group I (Obesity group): 112 patients with obesity (BMI ≥ 40 kg/m2), among whom 78 were women (mean age, 43.0 ± 11.4 years) and 34 were men (mean age, 49.56 ± 15.33 years), qualified for EGD as a routine part of the preparation for LSG. The body composition of the study patients was analyzed through dual-energy X-ray absorp- tiometry (DXA) with Lunar Idxa (GE Healthcare, Chicago, IL, USA). The study included solely those patients qualified for LSD as, in line with the guidelines of the National Insti- tutes of Health [13], this procedure represents the vast majority (85%) of bariatric surgeries performed at our center (1st Clinic of General and Endocrinological Surgery) [13]. Some patients from the obesity group reported mild gastrointestinal ailments, such as postpran- dial fullness and regurgitation, during the preparation for EGD. Drugs for reducing the acidity (PPI) were taken by 37 (33.6%) patients. Two patients eventually resigned from J. Clin. Med. 2021, 10, 2982 3 of 13 bariatric treatment and withdrew their consent for the publication of their EGD findings, ultimately resulting in Obesity group consisting of 110 participants. Group II (Control group): 110 patients with normal body weight (BMI between 18.9 and 24.9 kg/m2), among whom 66 were women (mean age, 44.52 ± 16.34 years) and 45 were men (mean age, 45.68 ± 13.0 years), referred for EGD by a gastroenterologist because of various upper gastrointestinal ailments (regurgitation, nausea, vomiting, epigastric pain/burning sensation, heartburn, morning hoarseness, dry cough, postprandial satiety associated with the sense of gastric fullness, and early postprandial fullness).
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